Faculty Bibliography

BACKGROUND: The Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) comprises over 100 general practices in England, with a population of around 1 million, providing a public health surveillance system for England and data for research. AIM: To demonstrate the scope of data with the RCGP Annual Report 2014-2015 (May 2014 to April 2015) by describing disparities in the presentation of six common conditions included in the report. DESIGN AND SETTING: This is a report of respiratory and communicable disease incidence from a primary care sentinel network in England. METHOD: Incidence rates and demographic profiles are described for common cold, acute otitis media, pneumonia, influenza-like illness, herpes zoster, and scarlet fever. The impact of age, sex, ethnicity, and deprivation on the diagnosis of each condition is explored using a multivariate logistic regression. RESULTS: With the exception of herpes zoster, all conditions followed a seasonal pattern. Apart from pneumonia and scarlet fever, the odds of presenting with any of the selected conditions were greater for females (P<0.001). Older people had a greater probability of a pneumonia diagnosis (>/=75 years, odds ratio [OR] 6.37; P<0.001). Common cold and influenza-like illness were more likely in people from ethnic minorities than white people, while the converse was true for acute otitis media and herpes zoster. There were higher odds of acute otitis media and herpes zoster diagnosis among the less deprived (least deprived quintile, OR 1.32 and 1.48, respectively; P<0.001). CONCLUSION: The RCGP RSC database provides insight into the content and range of GP workload and provides insight into current public health concerns. Further research is needed to explore these disparities in presentation to primary care.

AIMS: To describe the proportion of glucose tests with unrecorded provenance in routine primary care data and identify the impact on clinical practice. METHODS: A cross-sectional analysis was conducted of blood glucose measurements from the Royal College of General Practitioner Research and Surveillance Centre database, which includes primary care records from >100 practices across England and Wales. All blood glucose results recorded during 2013 were identified. Tests were grouped by provenance (fasting, oral glucose tolerance test, random, none specified and other). A clinical audit in a single primary care practice was also performed to identify the impact of failing to record glucose provenance on diabetes diagnosis. RESULTS: A total of 2 137 098 people were included in the cross-sectional analysis. Of 203 350 recorded glucose measurements the majority (117 893; 58%) did not have any provenance information. The most commonly reported provenance was fasting glucose (75 044; 37%). The distribution of glucose values where provenance was not recorded was most similar to that of fasting samples. The glucose measurements of 256 people with diabetes in the audit practice (size 11 514 people) were analysed. The initial glucose measurement had no provenance information in 164 cases (64.1%). A clinician questioned the provenance of a result in 41 cases (16.0%); of these, 14 (34.1%) required repeating. Lack of provenance led to delays in the diagnosis of diabetes [median (range) 30 (3-614) days]. CONCLUSIONS: The recording of glucose provenance in UK primary care could be improved. Failure to record provenance causes unnecessary repeated testing, delayed diagnosis and wasted clinician time

BACKGROUND: High serum phosphate is associated with coronary artery disease in patients with normal and impaired renal function. We asked: Does the serum phosphate range provide prediction of primary cardiac events? We extracted coded primary care data for over 100,000 patients from a database of 135 primary medical practices. Patients aged between 18 and 90 years without pre-existing cardiovascular diagnoses were included from a potential sample of over 1.2 million individuals. METHODS AND FINDINGS: Binary logistic regression models were used to evaluate the contribution of QRISK factors and electrolytes, including serum phosphate, to cardiac outcomes at five and nine years following an initial phosphate measurement. At five-year review (n = 113,993), low serum phosphate (OR 1.75, 95%CI 1.36-2.23, p<0.001), high-normal (OR 1.50, 95%CI 1.29-1.74, p<0.001), and high serum phosphate (OR 1.74, 95%CI 1.06-2.70, p = 0.02) were long-term risk factors for primary cardiac disease events after adjusting for confounding variables. A similar pattern was seen at our nine-year review. CONCLUSIONS: The extremes of serum phosphate may confer cardiac event risk with a U-shaped trend. In particular, we raise new cardiac concerns for low serum phosphate in the general population. Also, the normal range for phosphate may require redefinition among healthy adults.

BACKGROUND: The aims of this study are the following: to describe the female population of reproductive age having bariatric surgery in the UK, to assess the age and ethnicity of women accessing surgery, and to assess the effect of bariatric surgery on factors that underlie fertility and pregnancy outcomes. METHODS: Demographic details, comorbidities, and operative type of women aged 18-45 years were extracted from the National Bariatric Surgery Registry (NBSR). A comparison was made with non-operative cases (aged 18-45 and BMI >/=40 kg/m2) from the Health Survey for England (HSE, 2007-2013). Analyses were performed using "R" software. RESULTS: Data were extracted on 15,222 women from NBSR and 1073 from HSE. Women aged 18-45 comprised 53 % of operations. Non-Caucasians were under-represented in NBSR compared to HSE (10 vs 16 % respectively, p < 0.0001). The NBSR group was older than the HSE group-median 38 (IQR 32-42) vs 36 (IQR 30-41) years (Wilcoxon test p < 0.0001). Almost one third of women in NBSR had menstrual dysfunction at baseline (33.0 %). BMI fell in the first year postoperatively from 48.2 +/- 8.3 to 37.4 +/- 7.5 kg/m2 (t test, p < 0.001). From NBSR, in the postoperative period, the prevalence of type 2 diabetes fell by 54 %, polycystic ovarian syndrome by 15 %, and any menstrual dysfunction by 12 %. CONCLUSIONS: Over half of all bariatric procedures are carried out on women of reproductive age. More work is required to provide prompt and equal access across ethnic groups. At least one in three women suffers from menstrual dysfunction at baseline. Bariatric surgery improves factors that underlie fertility and pregnancy outcomes. A prospective study is required to verify these effects.

BACKGROUND: Information technology-based interventions are increasingly being used to manage health care. However, there is conflicting evidence regarding whether these interventions improve outcomes in people with type 2 diabetes. OBJECTIVE: The objective of this study was to conduct a systematic review and meta-analysis of clinical trials, assessing the impact of information technology on changes in the levels of hemoglobin A1c (HbA1c) and mapping the interventions with chronic care model (CCM) elements. METHODS: Electronic databases PubMed and EMBASE were searched to identify relevant studies that were published up until July 2016, a method that was supplemented by identifying articles from the references of the articles already selected using the electronic search tools. The study search and selection were performed by independent reviewers. Of the 1082 articles retrieved, 32 trials (focusing on a total of 40,454 patients) were included. A random-effects model was applied to estimate the pooled results. RESULTS: Information technology-based interventions were associated with a statistically significant reduction in HbA1c levels (mean difference -0.33%, 95% CI -0.40 to -0.26, P<.001). Studies focusing on electronic self-management systems demonstrated the largest reduction in HbA1c (0.50%), followed by those with electronic medical records (0.17%), an electronic decision support system (0.15%), and a diabetes registry (0.05%). In addition, the more CCM-incorporated the information technology-based interventions were, the more improvements there were in HbA1c levels. CONCLUSIONS: Information technology strategies combined with the other elements of chronic care models are associated with improved glycemic control in people with diabetes. No clinically relevant impact was observed on low-density lipoprotein levels and blood pressure, but there was evidence that the cost of care was lower.

BACKGROUND: -In March 2008, the National Institute for Health and Care Excellence recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE) undergoing dental procedures in the United Kingdom, citing a lack of evidence of efficacy and cost-effectiveness. We have performed a new economic evaluation of AP on the basis of contemporary estimates of efficacy, adverse events, and resource implications. METHODS: -A decision analytic cost-effectiveness model was used. Health service costs and benefits (measured as quality-adjusted life-years) were estimated. Rates of IE before and after the National Institute for Health and Care Excellence guidance were available to estimate prophylactic efficacy. AP adverse event rates were derived from recent UK data, and resource implications were based on English Hospital Episode Statistics. RESULTS: -AP was less costly and more effective than no AP for all patients at risk of IE. The results are sensitive to AP efficacy, but efficacy would have to be substantially lower for AP not to be cost-effective. AP was even more cost-effective in patients at high risk of IE. Only a marginal reduction in annual IE rates (1.44 cases in high-risk and 33 cases in all at-risk patients) would be required for AP to be considered cost-effective at pound20 000 ($26 600) per quality-adjusted life-year. Annual cost savings of pound5.5 to pound8.2 million ($7.3-$10.9 million) and health gains >2600 quality-adjusted life-years could be achieved from reinstating AP in England. CONCLUSIONS: -AP is cost-effective for preventing IE, particularly in those at high risk. These findings support the cost-effectiveness of guidelines recommending AP use in high-risk individuals.

BACKGROUND: A key component to achieving good patient outcomes is having the right type and number of healthcare professionals with the right resources. Lack of investment in infrastructure required for producing and retaining adequate numbers of health professionals is one reason, and contextual factors related to socioeconomic development may further explain the trend. Therefore, this study sought to explore the relationships between country-level contextual factors and healthcare human resource production (defined as worker-to-population ratio) across 184 countries. METHODS: This exploratory observational study is grounded in complexity theory as a guiding framework. Variables were selected through a process that attempted to choose macro-level indicators identified by the interdisciplinary literature as known or likely to affect the number of healthcare workers in a country. The combination of these variables attempts to account for the gender- and class-sensitive identities of physicians and nurses. The analysis consisted of 1 year of publicly available data, using the most recently available year for each country where multiple regressions assessed how context may influence health worker production. Missing data were imputed using the ICE technique in STATA and the analyses rerun in R as an additional validity and rigor check. RESULTS: The models explained 63 % of the nurse/midwife-to-population ratio (pseudo R 2 = 0.627, p = 0.0000) and 73 % of the physician-to-population ratio (pseudo R 2 = 0.729, p = 0.0000). Average years of school in a country's population, emigration rates, beds-per-1000 population, and low-income country statuses were consistently statistically significant predictors of production, with percentage of public and private sector financing of healthcare showing mixed effects. CONCLUSIONS: Our study demonstrates that the strength of political, social, and economic institutions does impact human resources for health production and lays a foundation for studying how macro-level contextual factors influence physician and nurse workforce supply. In particular, the results suggest that public and private investments in the education sector would provide the greatest rate of return to countries. The study offers a foundation from which longitudinal analyses can be conducted and identifies additional data that may help enhance the robustness of the models.